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<br /> STATE OF NEBRASKA
<br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HEAL M AgQ1t IV1,J, iN VICES, IT CERTIFIES
<br /> THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBR.4S APbEPARTMtNT;,OF hff LTH AND
<br /> HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FO VM4 /V~6l~t7~j i`'~ f f
<br /> DATE OF ISSUANCE
<br /> „r
<br /> 11/22/2010 A tA'Tf f5TRA'h
<br /> 201009604 r Alp -.MENTQF HM tA*IVV
<br /> LINCOLN, NEBRASKA MA 54~ I ES (4 . HEALTH AND STATE of NEaRASK DEPARTMENTERTIFICATEOFOF DEATHHUMArt sFrtv16E% I Ju { Y 1 ; '1003345
<br />
<br /> 1. DECEDENT'S-NAME (First, Middle, Last, Suffix) 2. SEX 4i60 DEATH (Mo., Day, Yr.)
<br /> Lester Glenn Husted Male November 16, 2010
<br /> 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH sa. AGE - Last Birthday Ob. UNDER 1 YEAR 5c. UNDER 1 DAY S. DATE OF BIRTH (Mo., Day, Yr.)
<br /> (Yrs.) MOS. DAYS HOURS MINS.
<br /> Beaver, Oklahoma 62 February 15, 1948
<br /> 7. SOCIAL SECURITY NUMBER 8a. PLACE OF DEATH
<br /> 509-50-4290 HOSPITAL ® inpatient OTHER ❑ Nursing Home/LTC ❑ Hospice Facility
<br /> Ob. FACILITY-NAME (if not Institution, give street and number) ER/Outpatlent ❑ Decedent's Home
<br /> Saint Francis Medical Center ❑ DOA ❑ Other (specify)
<br /> W Sc. CITY OR TOWN OF DEATH (Include Zip Coda) 8d. COUNTY OF DEATH
<br /> S Grand Island 68803 Hall
<br /> 9a. RESIDENCE-STATE 9b. COUNTY 9c. CITY OR TOWN
<br /> z Nebraska Hall Doniphan
<br /> 0 9d. STREET AND NUMBER e. APT. NO. 9f. ZIP CODE 99. INSIDE CITY LIMITS
<br /> 118 Leisure Lake Rd. 68832 ❑ YES ® NO
<br /> 10a. MARITAL STATUS AT TIME OF DEATH ® Married ❑ Never Married 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name
<br /> ❑ Married, but separated © Widowed ❑ Divorced ❑ Unknown Cindy Kay Reher
<br /> 11. FATHER'S•NAME (First, Middle, Last, Suffix) 12. MOTHER'S-NAME (First, Middle, Malden Surname)
<br /> Glenn Husted Charlene Bond
<br /> a 13. EVER IN U.S. ARMED FORCES? Give dates of service If Yes. 14a. INFORMANT-NAME 14b. RELATIONSHIP TO DECEDENT
<br /> E
<br /> $ (Yes, No, or Unk.) No Cind Kay Husted Spouse
<br /> a 15. METHOD OF DISPOSITION 16a. EMBALMER-SIGNATURE 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.)
<br /> F ❑ Burial ❑ Donation
<br /> Not Embalmed November 20, 2010
<br /> ® Cremation ❑ Entombment 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE
<br /> ❑ Removal ❑ Other (Specify)
<br /> Central Nebraska Cremation Services Gibbon Nebraska
<br /> 17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, City or Town, State) 17b. Zip Code
<br /> All Faiths Funeral Home, 2929 S. Locust Street, Grand Island, Nebraska 68801
<br /> CAUSE AT (See Instructions and examples)__
<br /> 16. PART I. Enter the ch0in of oven -diseases, Injuries, or complicatlonsdhat directly caused the death. 00 NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
<br /> respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary.
<br /> IMMEDIATE CAUSE; onset to death
<br /> IMMEDIATE CAUSE (Final a) Septic Shock Days
<br /> disease or condition resulting
<br /> In death) DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Sequentially list conditions, If b) Pneumonia Days
<br /> any, leading to the cause listed
<br /> on line a.
<br /> DUE TO, OR AS A CONSEQUENCE OF: onset to death
<br /> Enter the UNDERLYING CAUSE C)
<br /> (disease or Injury that initiated
<br /> he events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: Onset to death
<br /> LAST d)
<br /> 18. PART 11. OTHER SIGNIFICANT CONDITIONS-Conditions contributing to the death but not resulting in the underlying cause given in PART I. 19. WAS MEDICAL EXAMINER
<br /> Acute Renal Failure, Atrial Fibrillation, Disseminated Intravascular Coagulopathy, Obstructive Sleep Apnea OR CORONER CONTACTED?
<br /> W ❑ YES ® NO
<br /> LL 20, IF FEMALE: 21a. MANNER OF DEATH 21b. IF TRANSPORTATION INJURY 21c. WAS AN AUTOPSY PERFORMED?
<br /> ❑ Not pregnant within past year ® Natural ❑ Homicide ❑ Driver/Operator [@ YES ❑ NO
<br /> ❑ Pregnant at time of death ❑ Accident ❑ Pending Investigation © Passenger
<br /> ❑ Net pregnant, but pregnant within 42 days of death ❑ suicide Could not be determined Pedestrian 21d. WERE AUTOPSY FINDINGS AVAILABLE
<br /> ` ❑
<br /> ❑ Not pregnant, but pregnant 43 days to 1 year before death ~ Other (Specify) TO COMPLETE CAUSE OF DEATH?
<br /> ❑ Unknown if pregnant within the past year ❑ YES ® NO
<br /> 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 122c. PLACE OF INJURY-At home, farm, street, factory, office building, construction site, ate. (Specify)
<br /> 22d. INJURY AT WORK? 122e. DESCRIBE HOW INJURY OCCURRED
<br /> F
<br /> ❑ YES NO
<br /> 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITYrTOWN STATE ZIP CODE
<br /> 23a. DATE OF DEATH (Mo., Day, Yr.) 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH
<br /> .93 November 16, 2010 Z 3
<br /> C 23b. DATE SIGNED (Mo., Day, Yr.) 23c. TIME OF DEATH 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD
<br /> t; November 19, 2010, 04;&5 PM
<br /> _ 3d. Yo the best of my knowNedq~,-death il'cggrae sR p1i , j 24s. On the basis of examination andlor inwetlgation, In my opinion death occurred at
<br /> F and due to the cause(s) stated. (signature and Title) E $ the time, date and place and due to the cause(s) stated. (Signature and Title)
<br /> Jay C. Anderson, MD ~ 8
<br /> 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a. HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 26b. WAS CONSENT GRANTED?
<br /> ❑ YES ® NO ❑ PROBABLY UNKNOWN ❑ YES ® NO Not Applicable If 26a Is NO ❑ YES ❑ NO
<br /> ADDRESS 1 JPHY31CIAN, PHYSICIAN ASSISTANT, CGRONER'S PHYSICIXN UK COUNTY ATTORNEY) (Type or Print)
<br /> Jay C. Anderson, MO, 729 North Custer Avenue, Grand Island, Nebraska, 68803
<br /> 28a. REGISTRAR'S SIGNATURE 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
<br /> r November 19, 2010
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